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REACTIVE OR PROACTIVE: REACTIVE OR PROACTIVE: WHICH IS BEST IN RENAL WHICH IS BEST IN RENAL REPLACEMENT THERAPY REPLACEMENT THERAPY PHOSPHATE CONTROL?PHOSPHATE CONTROL?
Joanna Campion-SmithGurudutta VenkateshaMolly McLaughlinMeeta MallikPatrick Davies
On behalf of the Trent Renal Critical Care Network
Hypophosphataemia is Hypophosphataemia is common in critically ill common in critically ill patientspatientsPredisposed by:
◦Malnutrition & inadequate body stores
◦Sepsis◦Hyperventilation◦Glucose infusions
Side effects include:◦Muscle weakness◦Myocardial dysfunction◦Encephalopathy
BackgroundBackgroundCRRT fluids:
◦Bicarbonate-buffered solutions◦Containing:
Calcium Magnesium Sodium Chloride Lactate Glucose +/- Potassium
But no phosphate
Maintenance of Maintenance of normophosphataemianormophosphataemia
A balancing act:
Adequate phosphate removal
Prevention of hypophosphataemia
Two possible solutionsTwo possible solutions
What happens in the UK?
Straw poll of 9 UK PICUs:
7 bolus correct 2 add to CRRT fluids
Is one method better?
Phosphate stability in CRRT Phosphate stability in CRRT fluidsfluids
Work by Wignell, McLaughlin & Davies from our unit (poster presentation at this meeting)
Chemical stability of sodium glycerophosphate in CRRT fluids proven up to 48h
Calcium and bicarbonate also stable
AimsAimsCompare phosphate level
stability in CRRT patients who had bolus correction vs continuous correction
One previous paediatric study has suggested that continuous correction improves phosphate control (Santiago et al.)
MethodsMethods
2 PICUs◦Same CRRT machine & fluids◦Same CRRT protocols◦Different phosphate correction protocols
MethodsMethods
Retrospective analysis of phosphate control of all patients who underwent CRRT during a 13 month period
Study populationStudy population
DemographicsDemographicsAge
◦ Mean: 3.4 years
◦ Range: 0 – 13.1 years
Weight
◦ Mean: 14.8 kg
◦ Range: 2.8 – 48 kg
CRRT duration
◦ Mean: 65.3 hours
◦ Range: 0.5 – 216 hours
Underlying diagnosisUnderlying diagnosis
Indications for CRRTIndications for CRRT
More hypophosphataemic More hypophosphataemic episodes in the bolus groupepisodes in the bolus group
147 12 hourly blood
tests
57 episodes ofhypophosphata
emia
1 episode per 22.5 hours in the
bolus group
1 episode per 31.3 hours in the
continuous correction
groupp =
0.0019
29 in bolus group
(38 normal)
23 in continuous correction group
(57 normal)
More bolus patients More bolus patients hypophosphataemic at 24 hourshypophosphataemic at 24 hours
Bolus group
Continuous correction group
% patients hypophosphataemic at 24 hours
Depth of Depth of hypophosphataemia greater hypophosphataemia greater in bolus groupin bolus group
Phosphate level mean Phosphate level mean variancevariance
Conclusions & Conclusions & RecommendationsRecommendationsContinuous correction:
◦Tighter phosphate control◦With fewer hypophosphataemic
episodes
No documented side effects in either group
We recommend addition of phosphate to CRRT fluids
ReferencesReferencesWignell A et al., Is the addition of
Phosphate to Continuous Venous-Venous Haemofiltration fluids safe? (2011)
Santiago MJ et al., Hypophosphataemia and phosphate supplementation during continuous renal replacement therapy in children. Kidney International (2009) 75, 312-316
QUESTIONSQUESTIONS
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